STATE OF ILLINOIS) )SS COUNTY OF WILL ) IN THE CIRCUIT COURT OF THE TWELFTH JUDICIAL CIRCUIT WILL COUNTY, ILLINOIS In the Matter of the Petition of And CASE NO. TO ADOPT AFFIDAVIT OF ADOPTING PARENTS A. The following are the costs, expenses, contributions, fees, compensation or other things of value either paid, given ord t po romise be paid or given in the above entitled matter: NAME AMOUNT Hospital $ Obstetrician Pediatrician Guardian ad Litem (Child) Guardian ad Litem (Minor Parent) Biological Parent(s): Medicine Living Expenses Other Expenses Other Payments, Gifts or Donations Agency (Name) Amount of Bill Promised Contribution (whether or not paid) Other (Specify) Attorney Fees and Court Costs TOTAL $ American LegalNet, Inc. www.USCourtForms.com>>>> 2 B. We learned of the availability of this child as follows: (Adopting Parents) (Adopting Parents) Signed and sworn to before me , 20 (Notary Public) AFFIDAVIT OF ATTORNEY OF RECORD STATE OF ILLINOIS ) ) SS COUNTY OF WILL ) I, , being first duly sworn and on oath, depose and say that I have read the above and foregoing Affidavit and, to the best of my knowledge and belief, the contents thereondf ar coe trrrue aect. (Attorney) Signed and sworn to before me , 20 (Notary Public) American LegalNet, Inc. www.USCourtForms.com